Director's Report to the National Advisory Council on Drug Abuse - September, 2008

Research Findings - Services Research

Oxford House Post-Treatment Residency Increases Sobriety, Efficacy to Remain Abstinent, and Earned Income

Oxford Houses are recovery home residences for individuals with substance abuse and dependence problems who seek a supportive, democratic, mutual-help setting. A national US sample of Oxford House (OH) residents (n=897: 604 men, 293 women) were recruited and interviewed at an initial baseline phase and then re-interviewed at three subsequent 4-month intervals. Change in cumulative abstinence was predicted using latent growth modeling (LGM) by low support for alcohol use, abstinence self-efficacy, and length of residency in OH (i.e., less than versus >=6 months), even after controlling for initial time spent in OH (model X2 =179, df = 74; NFI=.98, RFI=.98, CFI=.99, RMSEA=.04). Average monthly income of $941.90 was significantly higher than $794 at baseline (p

Post-Treatment Recovery Management Check-ups Improve Patient Outcomes

This article examines the effectiveness of quarterly Recovery Management Checkups (RMCs) for people with substance use disorders by level of co-occurring mental disorders (34% none, 27% internalizing disorders, and 39% internalizing and externalizing) across two randomized experiments with 92% to 97% follow-up. The 865 participants are 82% African American, 53% female, and age 37 on average. RMC involves identification of those in need of treatment, motivational interviews, and treatment linkage assistance. Results show RMC is effective in linking participants in need to treatment, with equal or better outcomes among those with more mental disorders. The data support the utility of monitoring and re-intervention for clients with co-occurring disorders. Rush, B., Dennis, M., Scott, C., Castel, S., and Funk, R. The Interaction of Co-occurring Mental Disorders and Recovery Management Checkups on Substance Abuse Treatment Participation and Recovery. Eval. Rev., 32(1), pp. 7-38, 2008.

This study used a group-based modeling approach to classify 934 adult individuals who entered chemical dependency treatment in a private, managed care health plan to into distinct trajectories of psychiatric status. It then estimated the statistical association between membership in these trajectory groups and substance use (SU) outcomes over the 9 year follow up period. Four distinct groups are identified: Low severity, deteriorating, improving, and high severity. Results from multivariate logistic generalized estimating equation models reveal that psychiatric severity trajectory is associated with lower odds of being abstinent from drugs during the 9 year follow up period (OR deteriorating 0.61 (CI 0.42-0.87); improving 0.61 [CI 0.40-0.93], high severity 0.43 (CI 0.29-0.66). Associations with alcohol abstinence were not statistically significant. Chi, F., and Weisner, C. Nine-Year Psychiatric Trajectories and Substance Use Outcomes: An Application of the Group-Based Modeling Approach. Eval. Rev., 32(1), pp. 39-58, 2008.

Smoking Trends May Underly Increasing Education Level Differences in Health Status Relying on Data from the Multiple Cause of Death File and the National Longitudinal Mortality Study

This study examines educational disparities in mortality and life expectancy among non-Hispanic blacks and whites in the 1980s and 1990s. Age-standardized death rates per 100,000 Americans were estimated by education, race, sex and cause between 1990 and 2000. Differences in life expectancies between those with a high school diploma and those with some college education were significant. In 2000, a 25 year old with a high-school diploma could expect to live less than 50 years, until age 75, while a 25 year old with some college could expect to live 7 years longer. This gap had increased by about 30 percent over the study time period. Lung cancer and COPD, two diseases attributable largely to tobacco use, accounted for 21 percent of this widening gap overall, and 25 percent of the gap for less-educated white women over the age of 45, who have shown more modest declines in smoking rates. The gaps are increasing because, for most groups, longevity for more highly-educated individuals is increasing while that for less-educated groups is remaining the same. Meara, E., Richards, S., and Cutler, D. The Gap Gets Bigger: Changes In Mortality and Life Expectancy By Education, 1981-2000. Health Aff (Millwood), 27(2), pp. 350-360, 2008.

The Long-Term Impact of Drug Court on Recidivism

The current study examined the long-term impact of drug court participation compared to regular probation. In a quasi-experimental design, the recidivism was examined of 475 drug-involved offenders under supervision. The sampling frame consisted of adult offenders who entered community supervision on either felony probation or drug offender probation in Hillsborough County, FL, from Feb. through Sept. 2002, and were determined to be drug involved, had at most one prior prison commitment, at most two supervision terms. Analytic methods were also used to control for differences between the drug court and non drug court samples. Using a combination of self-reported data (collected through in-person interviews at baseline, i.e., the beginning of supervision) and administrative records, the study employed a repeated measures framework (examining five 6-month time periods from baseline to 30 months post-baseline) and used generalized estimating equations to compare the likelihood of being arrested between drug court participants and a matched sample of comparison offenders. The results indicate that participation in drug court was associated with a significant decrease in the likelihood of being arrested in the 12-18 months post-baseline time period. Although the drug court effect was somewhat delayed (it was not significant prior to 12 months) and short-lived (it was not significant after 18 months), the fact that significant program effects were observed during a time period that coincides with the conclusion of drug court participation for graduates and a time period well beyond initial program exposure, suggests that drug court participants are more likely than comparable offenders not exposed to drug court to remain arrest free when no longer under community supervision. Krebs, C., Lindquist, C., Koetse, W., and Lattimore, P. Assessing the Long-Term Impact of Drug Court Participation on Recidivism with Generalized Estimating Equations. Drug Alc. Depend., 91(1), pp. 57-68, 2007.

Larger Methadone Maintenance Clinics May be More Efficient

Using data from 159 methadone treatment programs (MTPs') that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project, the authors estimated two modified translog cost functions (multivariate regression models that allow for nonlinear relationships by regressing log total costs on the logs of measures of outputs, outputs squared, input prices, facility and client characteristics) to determine the extent to which this industry experiences economies of scale and scope. The first cost function estimation, a single product cost function which used log of patient days as the output variable, revealed that a 10% increase in annual patient days evaluated at the mean is associated with an 8.2% increase in total cost, suggesting that these programs experience economics of scale (i.e. larger programs have lower average costs). As expected from economic theory, higher counselor wages in the program's location were positively associated with higher total costs, although the effects of other input prices included in the model (nurses' wages and office space costs) were not significant. The second model estimated a multi-product cost function, using the logs of annual counseling hours, case management hours, intake hours, and medical hours, and their squares, as measure of output. A multi-product cost function provides estimates of economies of scope which occur when the average cost of producing one output decreases as the volume of another output increases. This second model revealed economies of scale in the production of each of these outputs separately but only weak evidence of economies of scope. Further research is needed to investigate the relationship between client characteristics and costs, as only rough measures of client severity were included in this analysis due to data limitations. Dunlap, L., Zarkin, G., and Cowell, A. Examining Variation in Treatment Costs: A Cost Function for Outpatient Methadone Treatment Programs. Health Serv. Res., 43(3), pp. 931-950, 2008.

Trial of Computerized Screening for Adolescent Behavioral Concerns

The primary causes of adolescent morbidity and deaths are: injury risk, depressive symptoms, and substance use. The goal of this randomized, controlled trial was to determine whether computerized screening with real-time printing of results for pediatricians increased the identification of these adolescent behavioral concerns. A total of 878 primary care patients 11 to 20 years of age participated in computerized behavioral screening (The Health eTouch System) in waiting rooms of 9 urban clinics. These clinics all served predominantly low-income patients. The clinics were randomly assigned to have pediatricians receive screening results either just before face-to-face encounters with patients (immediate-results condition) or 2 to 3 business days later (delayed-results condition). It was found that fifty-nine percent of Health eTouch respondents had positive results for at least one of the following behavioral concerns: injury risk behaviors, significant depressive symptoms, or substance use. Sixty-eight percent of youths in the immediate-results condition who screened positive were identified as having a problem by their pediatrician. This was significantly higher than the recognition rate of 52% for youths in the delayed-results condition. This study shows that the immediate provision of an adolescent's self-report of behavioral concerns to pediatrician increased recognition of those problems, compared with the delayed provision of results. Stevens, J., Kelleher, K., Gardner, W., Chisolm, D., McGeehan, J., Pajer, K., and Buchanan, L. Trial of Computerized Screening for Adolescent Behavioral Concerns. Pediatrics, 121(6), pp. 1099-1105, 2008.

Buprenorphine Can Be Successfully Integrated Within an Outpatient Agonist Treatment Facility

Buprenorphine may be used to treat opioid dependence in office-based settings, but treatment models are needed to ensure access to the psychosocial services needed by many patients. The authors describe a novel buprenorphine treatment program colocated with methadone maintenance and outpatient chemical dependency services. They conducted a retrospective chart review of the first 40 consecutive patients initiating buprenorphine treatment in this program to determine characteristics associated with treatment retention. Exclusion criteria were current alcohol or benzodiazepine dependence. Secondary drug users and patients who were psychiatrically or medically ill were included. At 6 months, 60% (n = 24) were retained, 13% (n = 5) tested positive for opiates, and 25% (n = 10) tested positive for secondary substances. Patients who were older (odds ratio [OR] per year of age = 1.1, confidence interval [CI] = 1.0-1.2) and those who were employed (OR = 9.8, CI = 1.8-53.1) were more likely to remain in treatment, but other variables were not associated with retention. The authors' experience demonstrates that buprenorphine can be successfully integrated into outpatient substance abuse treatment. Whitley, S., Kunins, H., Arnsten, J., and Gourevitch, M. Collocating Buprenorphine with Methadone Maintenance and Outpatient Chemical Dependency Services. J. Subst. Abuse Treat., 33(1), pp. 85-90, 2007.

Water Pipe Tobacco Smoking on a U.S. College Campus: Prevalence and Correlates

Water pipe tobacco smoking is reported to be growing in popularity, particularly among college students. This study examined the prevalence of water pipe tobacco smoking and perceptions in a university-based population. This was a cross-sectional Internet-based survey of first-year university students, which examined water pipe tobacco smoking and other tobacco use, risk perceptions, influences, and perceived social acceptability. Water pipe tobacco smoking within the past 30 days was reported by 20% (151/744). Relative to never users, users were more likely to perceive water pipe tobacco smoking as less harmful than cigarette use. Because water pipe tobacco smoking is increasing in prevalence and because it can involve toxicant inhalation at even greater levels than with cigarette smoking, it represents a growing public health issue. Eissenberg, T., Ward, K., Smith-Simone, S., and Maziak, W. Water Pipe Tobacco Smoking on a U.S. College Campus: Prevalence and Correlates. J. Adolesc. Health, 42(5), pp. 526-529, 2008.

Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programs (MMTPs) reporting that 60-90 percent of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42-82 percent of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programs throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider, initiate HCV treatment or both. Gaining a better understanding of drug users' perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future. Munoz-Plaza, C., Strauss, S., Astone-Twerell, J., Des Jarlais, D., Gwadz, M., Hagan, H., Osborne, A., Rosenblum, A., and Rosenblum, A. Exploring Drug Users Attitudes and Decisions Regarding Hepatitis C (HCV) Treatment in the U.S. Int. J. Drug Policy, 19(1), pp. 71-78, 2008.

Cocaine Use and Hypertensive Renal Changes in HIV Infected Individuals

Cocaine causes kidney damage, but data linking cocaine use to chronic kidney disease in HIV patients is not described. This study was conducted to evaluate the possible association of cocaine use and histopathologic findings on biopsy in this population. Kidney biopsies that were performed in HIV-infected patients during the course of 11 years were reviewed. Demographic and clinical data were collected. Hypertensive changes were defined on the basis of the Banff 97 classification. Criteria of both arterial intimal fibrosis and thickening and hyaline arteriolosclerosis were used and graded as absent (0), mild (1) moderate (2), and severe (3). Hypertensive renal changes were considered present when the combined pathology score was > or = 2. To minimize confounding, those with hypertension or diabetes were excluded. Of the 193 HIV patients who underwent kidney biopsy, 53 had no history of hypertension or diabetes with HIV infection. Of those, 29 (55%) had hypertensive renal changes on kidney biopsy. Cocaine use was present in 16 (55%) of 29 with hypertensive renal changes compared with six (25%) of 24 without hypertensive renal changes (odds ratio [OR] 3.7; 95% confidence interval [CI] 1.2 to 11.7). In the adjusted analyses, only age (/yr; OR 1.08; 95% CI 1.00 to 1.16) and cocaine use (OR 3.55; 95% CI 1.04 to 12.14) were significantly associated with hypertensive renal changes on renal biopsy. Cocaine use is associated with hypertensive renal changes in HIV-infected patients in the absence of hypertension and diabetes. Fine, D., Garg, N., Haas, M., Rahman, M., Lucas, G., Scheel, P., and Atta, M. Cocaine Use and Hypertensive Renal Changes in HIV Infected Individuals. Clin. J. Am. Soc. Nephrol., 2(6), pp. 1125-1130, 2007.

There is growing concern about illicit rural stimulant use, especially regarding methamphetamine use and its health consequences. This study describes associations between aspects of stimulant use and illness experience in rural areas, with additional focus on the role of demographic characteristics in these associations. The research participants were 710 stimulant drug users who were recruited from rural areas of Arkansas, Kentucky, and Ohio using Heckathorns' respondent-driven sampling method. Health was measured by self-reports of perceived health and extent of current, recent, and lifelong health problems. Drug use was measured with self-reports of type and frequency of use. Several associations were found between drug use and illness, controlling for demographics. Stimulant use pattern related significantly with the sum of health problems in the previous 6 months and the sum of lifetime illness diagnoses, after adjustment for demographic factors. Extent of illicit drug use in the past month and self-perceived drug and alcohol problems were associated with several measures of health. In this sample of stimulant users, methamphetamine use was associated with fewer recent medical problems than crack cocaine, combined crack and powder cocaine use, and use of all 3 of these stimulants. These results, across the 3 sites, suggest that prevalent assumptions about the methamphetamine 'plague' and its negative health consequences must be viewed cautiously and examined with additional research. Garrity, T., Leukefeld, C., Carlson, R., Falck, R., Wang, J., and Booth, B. Physical Health, Illicit Drug Use, and Demographic Characteristics in Rural
Stimulant Users. J. Rural Health, 23(2), pp. 99-107, 2007.

Impact of a Brief Training on Medical Resident Screening for Alcohol Misuse and Illicit Drug Use

Substance use screenings in primary-care medical settings require numerous initiatives including educational. This study assesses the impact on 24 medical residents of a 2.5-day curriculum combining experiential and manual-based training on screening for alcohol misuse and illicit drug use. A retrospective chart review of new primary care outpatients demonstrated that nearly all were asked about current alcohol use before and after curriculum participation. Adherence to national screening guidelines on quantification of alcohol consumption modestly improved (p < .05), as did inquiry about current illicit drug use (p < .05). Continued efforts are needed to enhance educational initiatives for primary care physicians. Gunderson, E., Levin, F., and Owen, P. Impact of a Brief Training on Medical Resident Screening for Alcohol Misuse and Illicit Drug Use. Am. J. Addict., 17(2), pp. 149-154, 2008.

Nurse Case-Managed Intervention for Latent Tuberculosis Among the Homeless

The efficacy of a nurse case-managed intervention was evaluated in subsamples of participants with one of the following characteristics: female gender, African American ethnicity, recruited from a homeless shelter, a history of military service, lifetime injection drug use, daily alcohol and drug use, poor physical health, and a history of poor mental health. The purpose of the study was to determine whether a validated nurse case managed intervention with incentives and tracking would improve adherence to latent tuberculosis infection treatment in subsamples of homeless persons with characteristics previously identified in the literature as predictive of non-adherence. A prospective 2-group site-randomized design was conducted with 520 homeless adults residing in 12 homeless shelters and residential recovery sites in the Skid Row region of Los Angeles from 1998 to 2003. Results revealed that daily drug users, participants with a history of injection drug use, daily alcohol users, and persons who were not of African American race or ethnicity had particularly poor completion rates, even in the nurse case-managed intervention program (48%, 55%, 54%, and 50%, respectively). However, the intervention achieved a 91% completion rate for homeless shelter residents and significantly improved latent tuberculosis infection treatment adherence in 9 of 12 subgroups tested (odds ratios = 2.51-10.41), including daily alcohol and drug users, when potential confounders were controlled using logistic regression analysis. It is concluded that nurse case management with incentives appears to be a good foundation for increasing adherence to 6-month isoniazid treatment in a variety of homeless subgroups and, in particular, for sheltered homeless populations. However, additional social-structural and environmental strategies are needed to address those at greatest risk of non-adherence. Nyamathi, A., Nahid, P., Berg , J., Burrage, J., Christiani, A., Aqtash, S., Morisky, D., and Leake, B. Efficacy of Nurse Case-Managed Intervention for Latent Tuberculosis Among Homeless Subsamples. Nurs. Res., 57(1), pp. 33-39, 2008.

Kratom (Mitragynia speciosa korth) is recognized increasingly as a remedy for opioid withdrawal by individuals who self-treat chronic pain. A case history was described of a patient who had abruptly ceased injection hydromorphone abuse; he self-managed opioid withdrawal and chronic pain using kratom. After co-administering the herb with modafinil he experienced a tonic-clonic seizure, but he reported only modest abstinence once kratom administration stopped. The identity of the plant matter he ingested was confirmed as kratom and no contaminants or adulterants were identified. High-throughput molecular screening and the binding affinity at mu, delta and kappa receptors of mitragynine was also performed. This is the first report of the self-treatment of chronic pain and opioid withdrawal with kratom. The predominant alkaloid of kratom, mitragynine, binds mu- and kappa-opioid receptors, but has additional receptor affinities that might augment its effectiveness at mitigating opioid withdrawal. The natural history of kratom use, including its clinical pharmacology and toxicology, are poorly understood. Boyer, E., Babu, K., Adkins, J., McCurdy, C., and Halpern, J. Self-Treatment of Opioid Withdrawal Using Kratom (Mitragynia Speciosa Korth). Addiction, 103(6), pp. 1048-1050, 2008.

HIV Treatment Adherence Among IDUs and the Role of Opioid Substitution Treatment (OST)

In the era of highly effective anti-retroviral therapy (ART), data show a significant difference in treatment outcomes between injecting drug users (IDUs) and non-IDUs. Factors that may contribute to suboptimal treatment outcomes in IDUs include delayed access to ART, competing comorbid diseases, psychosocial barriers and poor long-term adherence to ART. This review describes and compares several studies on adherence to ART and its correlates in HIV-infected individuals in general, then IDUs and finally those IDUs on opioid substitution treatment (OST). It highlights how ongoing drug use or OST can modify the pattern of these correlates. The aim is to extend all the experience acquired from these studies in order to optimize both access to care and adherence in those countries where HIV infection is mainly driven by IDUs and where ART and OST are only starting to be scaled up. The role of OST in fostering access to care and adherence to ART together with the promising results achieved to date using modified directly observed therapy (DOT) programs for patients taking methadone, allow us to emphasize the efficacy of a comprehensive care model which integrates substance dependence treatment, psychiatric treatment, social services, and medical treatment. The review concludes by suggesting areas of future research targeted at improving the understanding of both the role of perceived toxicity and patient-provider relationship for patients on ART and OST. Spire, B., Lucas, G., and Carrieri, M. Adherence to HIV Treatment Among IDUs and the Role of Opioid Substitution Treatment (OST). Int. J. Drug Policy, 18(4), pp. 262-270, 2007.

Patient non-attendance to scheduled sessions results in excessive costs to mental health and substance abuse providers and compromises the care of clients. This paper presents a comprehensive review of interventions that have been shown to increase session attendance rates in these settings. Unique to other review papers, reliability estimates were performed in the selection and evaluation of obtained studies. Reliability of article selection and evaluation strategies was excellent (.80 to .88). Study results indicate several attendance improvement methods appear to be particularly promising, such as scheduling appointments promptly, reminder letters and telephone calls, soliciting patient commitment, and helping to resolve obstacles to attending the session. The specific manner in which these interventions are implemented appears to influence session attendance rates. Moreover, some attendance improvement interventions are clearly effective in some settings, but not others. Specific recommendations are provided in light of the study findings. Lefforge, N., Donohue, B., and Strada, M. Improving Session Attendace in Metal Health and Substance Abuse Settings: A Review of Controlled Studies. Behav. Ther., 38(1), pp. 1-22, 2007.

Small Changes in Treatment Processes Can Lead to Big Improvements in Treatment Retention

The Network for the Improvement of Addiction Treatment (NIATx) teaches participating treatment centers to use process improvement strategies. A cross-site evaluation monitored impacts on days between first contact and first treatment and percent of patients who started treatment and completed two, three and four units of care (i.e., one outpatient session, 1 day of intensive outpatient care, and 1 week of residential treatment). The analysis included 13 agencies that began participation in August 2003, submitted 10-15 months of data, and attempted improvements in outpatient (n=7), intensive outpatient (n=4) or residential treatment services (n=4) (two agencies provided data for two levels of care). Days to treatment declined 37% (from 19.6 to 12.4 days) across levels of care; the change was significant overall and for outpatient and intensive outpatient services. Significant overall improvement in retention in care was observed for the second unit of care (72-85%; 18% increase) and the third unit of care (62-73%; 17% increase); when level of care was assessed, a significant gain was found only for intensive outpatient services. Small incremental changes in treatment processes can lead to significant reductions in days to treatment and consistent gains in retention. McCarty, D., Gustafson, D., Wisdom, J., Ford, J., Choi, D., Molfenter, T., Capoccia, V., and Cotter, F. The Network for the Improvement of Addiction Treatment (NIATx): Enhancing Access and Retention. Drug Alcohol Depend., 88(2-3), pp. 138-145, 2007.

Buprenorphine Found To Be Superior to Clonidine for Addiction Treatment

In June 2004, a community-based residential medical detoxification center switched from clonidine to buprenorphine treatment for all new and returning heroin clients. This study is a retrospective chart review of subject outcomes with clonidine (n = 100) versus buprenorphine (n = 100). Bivariate analysis suggested few cohort differences in pretreatment demographics and client characteristics. In contrast, buprenorphine was significantly associated with increased length of stay and treatment completion. The positive associations between buprenorphine and both treatment completion and length of stay persisted and were slightly enhanced after regression analysis adjusted for potential confounders. Additionally, clinical staff reported better subject engagement in treatment and psychosocial group sessions. This single-site study is an example of successful integration of an evidence-based treatment into community-based practice. Kovas, A., McFarland, B., McCarty, D., Boverman, J., and Thayer, J. Buprenorphine for Acute Heroin Detoxification: Diffusion of Research into Practice. J. Subst. Abuse Treat., 32(2), pp. 199-206, 2007.

Emotions that Move People from Pre-Contemplation to Contemplation of Behavior Change

Motivation for change has historically been viewed as the crucial element affecting responsiveness to drug treatment. Various external pressures, such as legal coercion, may engender motivation in an individual previously resistant to change. Dramatic relief may be the change process that is most salient as individuals internalize such external pressures. This process involves emotional arousal about one's current behavior and the psychological relief that can come from changing from Pre-contemplation to Contemplation--it is a trigger that prompts people to acknowledge, at an emotional level, their problem behavior and its impact on those around them. Fear, inspiration, guilt, and hope, for example, are some of the emotions that can promote dramatic relief and move people from Pre-contemplation to Contemplation. Results of structural equation modeling on data from 465 drug users (58.9% male; 21.3% Black, 34.2% Hispanic/Latino, and 35.1% White) entering drug treatment indicated that internal motivation and external pressure significantly and positively predicted dramatic relief and that dramatic relief significantly predicted attitudes towards drug treatment: chi (2) = 142.20, df = 100, p < 0.01; Robust Comparative Fit Index = 0.97, Root Mean Squared Error of Approximation = 0.03. These results indicate that when external pressure and internal motivation are high, dramatic relief is also likely to be high. When dramatic relief is high, attitudes towards drug treatment are likely to be positive. The findings indicate that interventions to get individuals into drug treatment should include processes that promote Dramatic Relief. Conner, B. T., Longshore, D., and Anglin, M. Modeling Attitude towards Drug Treament: The Role of Internal Motivation, External Pressure, and Dramatic Relief. J. Behav. Health Serv. Res, Special Issue, pp. 1-9, 2008.

Intensive Case Management Is Associated with Improved Outcomes For Women With Substance Use Disorders

The aim of this study is to identify factors that predict, mediate or moderate the effects of intensive case management (ICM) on longer-term drug abstinence outcomes in women on welfare. In a parent study women were assigned randomly to usual care (UC) or intensive case management (ICM). Treatment was provided for 12 weeks and follow-up continued for 15 months after study intake. A set of hypothesized mediators was assessed at month 3 and a rigorous four-step mediational model was tested using outcomes in months 4-15. Participants were 302 drug-dependent women applying and eligible for federal welfare and not currently in drug abuse treatment. The ICM intervention provided intensive treatment engagement including voucher incentives for treatment attendance and case management services; UC provided primarily referral to community treatment programs. Substance use outcomes were assessed using the time-line follow-back interview and confirmed using biological and collateral measures. The authors report that participants in ICM had more case manager contacts, better treatment engagement and more self-help attendance than did those in UC. Each of these variables predicted, and was shown to be a mediator of outcome, but case management contact was an especially robust mediator. Further, ICM effects were strongest for those who attended treatment least. Contrary to prediction, greater psychopathology and environmental stressors did not predict worse outcomes. Findings suggest that case management is an active intervention that may both facilitate and substitute for formal drug abuse treatment. Morgenstern, J., Blanchard, K., Kahler, C., Barbosa, K., McCrady, B., and McVeigh, K. Testing Mechanisms of Action for Intensive Case Management. Addiction, 103(3), pp. 469-477, 2008.

Data from the 1995-2000 Florida Hospital Discharge Data set were used to examine the incremental cost of marijuana co-morbidity among hospital inpatients with primary alcohol (n=2,130), mood (n=8,738), and thought disorder diagnoses (n=4,245). General linear modeling and propensity score methods were used to compare the hospital charges for these patients against patients with the same primary diagnoses but no marijuana co-morbidity (alcohol = 54,699, mood= 256,938, thought = 139,626 patients), holding other factors constant. Under the preferred specification, patients with both disorders incurred charges 7-8% higher per discharge than patients with the same primary diagnosis but no marijuana co-morbidity, for an incremental cost of $226 dollars on average. The estimates for mood and thought disorders were statistically insignificant. These results suggest that the healthcare costs of marijuana are not negligible and are worthy of further research. Pacula, R., Ringel, J., Dobkin, C., and Truong, K. The Incremental Inpatient Costs Associated with Marijuana Co-Morbidity Drug Alcohol Depend., 92(1-3), pp. 248-257, 2008.

Alcohol, Cannabis, and Methamphetamine Use and Other Risk Behaviors Among Black and Colored South African Women

There is a pressing need for brief behavioral interventions to address the intersection of high HIV prevalence, increasing substance use, and high-risk sex practices among South African women. The primary aim of this pilot, randomized trial was to examine whether an adapted evidence-based intervention would be equally, more, or less effective at reducing HIV risk behaviors when delivered using an individual or group format. The secondary aim was to examine differences between Black and Colored South African women across pre- and post-intervention measures of alcohol and illicit drug use and sex risk behaviors. The Cape Town Women's Health Co-Op was adapted from an evidence-based intervention known as the Women's Co-Op. Study participants included Black (n=60) and Colored (n=52) women living in the township communities of Cape Town, South Africa, who reported using illicit drugs and alcohol. Colored women reported greater methamphetamine use (13 days in the past 30 days) and Black women reported mostly cannabis use (27 days in the past 30 days). Although both groups reported having unprotected sex under the influence of alcohol and/or other drugs, Black women reported greater condom use and having one partner; Colored women reported having more than one sex partner. One-month post-intervention assessments indicated significant reductions in substance use and sex risk behaviors. After controlling for baseline measures, there were no significant differences between the two intervention conditions. Significant differences in risk behaviors were observed between Black and Colored South African women. However, both ethnic groups were responsive to the adapted intervention and no differences were found by intervention assignment. These findings support the assertion that group interventions may be more cost-effective in reaching at-risk women in resource-scarce environments. Larger studies are needed to show efficacy and effectiveness of woman-focused group prevention interventions. Wechsberg, W., Luseno, W., Karg, R., Young, S., Rodman, N., Myers, B., and Parry, C. Alcohol, Cannabis, and Methamphetamine Use and Other Risk Behaviors among Black and Colored South African Women: A Small Randomized Trial in the Western Cape. Int. J. Drug Policy, 19(2), pp. 130-139, 2008.

Corrections officials frequently use private contractors to operate in-prison, therapeutic community (TC) treatment programs. However, the recurrent competitive bidding process inherent in state agencies contracting for services sometimes results in a treatment-provider change. Few studies have focused on whether this change leads to better or worse treatment motivation and engagement for clients and how it might be evaluated. Using data collected during the larger Criminal Justice Drug Abuse Treatment Studies Performance Indicators for Corrections study, quantitative assessments of client functioning were made at two points in time. Changing to new treatment providers in three in-prison TC treatment facilities caused significant disruptions, leading to decreased client-counselor rapport and peer support as well as lower levels of treatment readiness, participation, and satisfaction of clients. Qualitative client and staff interviews provided further insight relevant for correctional administrators and treatment providers who may be considering similar changes. General recommendations for provider transition planning are offered. Saum, C., O'Connell, D., Martin, S., Hiller, M., Bacon, G., and Simpson, D. Tempest in a TC: Changing Treatment Providers for In-Prison Therapeutic Communities: Criminal Justice and Behavior, 34(9), pp. 1168-1178, 2007.

Meta-Analysis of Day Treatment and Contingency-Management Dismantling Research

Four successive randomized clinical trials studying contingency management (CM), involving various treatment arms of drug-abstinent housing and work therapy and day treatment (DT) with a behavioral component, were compared on common drug abstinence outcomes at two treatment completion points (2 and 6 months). The clinical trials were conducted from 1990 to 2006 in Birmingham, Alabama, with a total of 644 homeless persons with primary crack cocaine addiction. The meta-analysis utilized the weighted least squares approach to integrate data encompassing 9 different treatment arms to assess the effects of CM and DT (neither, DT only, CM only, and CM + DT) on a common estimate of prevalence of drug abstinence. Taken together, the results show much stronger benefits from CM + DT and from CM only than for DT alone. Throughout all of the Birmingham Homeless Cocaine Studies, the CM + DT consistently produced higher abstinence prevalence than did no CM. Schumacher, J., Milby, J., Wallace, D., Meehan, D., Kertesz, S., Vuchinich, R., Dunning, J., and Usdan, S. Meta-analysis of Day Treatment and Contingency-Management Dismantling Research: Birmingham Homeless Cocaine Studies (1990-2006). J. Consult. Clin. Psychol., 75(5), pp. 823-828, 2007.

Principal Stratification Designs to Estimate Input Data Missing Due to Death

Studies of cohorts of individuals after a critical event, such as an injury, were considered with the following characteristics. First, the studies are designed to measure 'input' variables, which describe the period before the critical event, and to characterize the distribution of the input variables in the cohort. Second, the studies are designed to measure 'output' variables, primarily mortality after the critical event, and to characterize the predictive (conditional) distribution of mortality given the input variables in the cohort. Such studies often possess the complication that the input data are missing for those who die shortly after the critical event because the data collection takes place after the event. Standard methods of dealing with the missing inputs, such as imputation or weighting methods based on an assumption of ignorable missingness are known to be generally invalid when the missingness of inputs is non-ignorable, that is, when the distribution of the inputs is different between those who die and those who live. To address this issue, the researchers propose a novel design that obtains and uses information on an additional key variable -- a treatment or externally controlled variable, which if set at its 'effective' level, could have prevented the death of those who died. It is shown that the new design can be used to draw valid inferences for the marginal distribution of inputs in the entire cohort, and for the conditional distribution of mortality given the inputs, also in the entire cohort, even under non-ignorable missingness. The crucial framework that was used is principal stratification based on the potential outcomes, here mortality under both levels of treatment. Using illustrative preliminary injury data, it is shown that this approach can reveal results that are more reasonable than the results of standard methods, in relatively dramatic ways. Thus, the current approach suggests that the routine collection of data on variables that could be used as possible treatments in such studies of inputs and mortality should become common. Frangakis, C., Rubin, D., An, M., and MacKenzie, E. Principal Stratification Designs to Estimate Input Data Missing Due to Death. Biometrics, 63(3), pp. 641-662, 2007.

Smoking-Cessation Media Campaigns and their Effectiveness Among Socioeconomically Advantaged and Disadvantaged Populations

The authors examined whether the impact of televised smoking cessation ads differed by a population's education and income. Longitudinal data from the Wisconsin Behavioral Health Survey, a statewide sample of 452 adult smokers who were interviewed in 2003 to 2004 and followed up 1 year later was used. Logistic regression was used to assess whether baseline recall of secondhand smoke ads and 'keep trying to quit' ads was associated with quit attempts and smoking abstinence at 1 year. Interaction terms were used to assess whether these associations differed by the smokers' education and income levels. It was found that overall, neither keep-trying-to-quit nor secondhand smoke ad recall was associated with quit attempts or smoking abstinence. Keep-trying-to-quit ads were significantly more effective in promoting quit attempts among higher-versus lower-educated populations. No differences were observed for secondhand smoke ads by the smokers' education or income levels. This study shows that some media campaign messages appear less effective in promoting quit attempts among less-educated populations compared with those who have more education. There is a need to develop media campaigns that are more effective with less-educated smokers. Niederdeppe, J., Fiore, M., Baker, T., and Smith, S. Smoking-Cessation Media Campaigns and their Effectiveness Among Socioeconomically Advantaged and Disadvantaged Populations. Am. J. Public Health, 98(5), pp. 916-924, 2008.

This study examined the rates and correlates of self-reported receipt for mental health services among 1,190 adolescents, aged 12-19, who were admitted to community-based substance abuse outpatient clinics and had a co-occurring mental health problem. Utilization of mental health service was ascertained 3 months post-intake. About one third (35%) of adolescents with a co-occurring mental health problem identified at intake received mental health service in the 3 months after treatment entry. After holding other correlates constant, history of mental health treatment, suicidal behavior, family history of mental disorder and insurance coverage at intake were associated with mental health service utilization at the 3-month follow up. Predictors of service utilization varied by gender and racial/ethnic status. The authors discuss implications for integrated substance use and mental health services. They recommend, for example, that substance abuse treatment programs provide a prompt and adequate mental health assessment for adolescents to design a treatment plan based on individual needs. In addition, youth with substance use and mental disorders have various and complex treatment needs, but may need additional insight and motivational counseling to address them. The authors also state that special attention and case management (e.g., linkage, advocacy) may be necessary for uninsured groups as they may be the least likely to obtain services without special assistance. Chan, Y., Godley, M., Godley, S., and Dennis, M. Utilization of Mental Health Services Among Adolescents in Community-Based Substance Abuse Outpatient Clinics. J. Behav. Health Serv. Res, 2007 Dec 21. E-pub ahead of print, (Special Issue), pp. 1-17, 2007.

Screening, Assessment, and Referral Practices in Adult Correctional Settings: A National Perspective

A national survey of adult prisons, jails, and community correctional agencies was conducted to examine the practices used to place offenders in appropriate treatment services. 289 administrators of adult facilities completed the survey (34% from prisons, 14.2% from jails, 24.6% from state-run community correctional facilities, and 27.2% from locally-run community correctional facilities). 58.2% of survey respondents reported the use of a standardized substance abuse-screening tool, and 34.2% reported use of an actuarial risk tool. The provision of higher intensity treatment programs, the use of standardized risk tools, and the provision of more community referral services were all independently associated with the use of a standardized substance abuse-screening tool. Taxman, F., Cropsey, K., Young, D., and Wexler, H. Screening, Assessment, and Referral Practices in Adult Correctional Settings: A National Perspective. Criminal Justice and Behavior, 34(9), pp. 1216-1234, 2007.

Review of Office-Based Maintenance Treatment of Opioid Dependence

The increasing global public health burden of heroin dependence and prescription opioid dependence warrants further expansion of treatment models. The most effective intervention for opioid dependence remains maintenance with methadone, a full mu-opioid receptor agonist, or buprenorphine, a partial mu-opioid receptor agonist. A growing body of evidence supports the use of opioid receptor agonist maintenance in office-based settings. Office-based opioid treatment (OBOT) can expand treatment access in a less stigmatized environment, which enables integrated care of co-morbid conditions. The authors discuss clinical and practical considerations when providing treatment for opioid dependence in traditional versus office-based settings include patient selection and monitoring, health economics, management of co-morbid conditions, and access to ancillary psychosocial treatment. OBOT provides an additional opportunity to help address the tremendous public health impact of opioid dependence. Gunderson, E. and Fiellin, D. Office-Based Maintenance Treatment of Opioid Dependence: How Does it Compare With Traditional Approaches? CNS Drugs, 22(2), pp. 99-111, 2008.

Treatment Attitudes, perceived social norms, and intentions were assessed for 376 counselors and 1083 clients from outpatient, methadone, and residential drug treatment programs regarding four medications used to treat opiate dependence: methadone, buprenorphine, clonidine, and ibogaine. Attitudes, social norms, and intentions to use varied by treatment modality. Methadone clients and counselors had more positive attitudes toward the use of methadone, whereas their counterparts in residential and outpatient settings had neutral or negative assessments. Across modalities, attitudes, perceived social norms, and intentions toward the use of buprenorphine were relatively neutral. Assessments of clonidine and ibogaine were negative for clients and counselors in all settings. Social normative influences were dominant across settings and medications in determining counselor and client intentions to use medications, suggesting that perceptions about beliefs of peers may play a critical role in use of medications to treat opiate dependence. Rieckmann, T., Daley, M., Fuller, B., Thomas, C., and McCarty, D. Client and Counselor Attitudes Toward the Use of Medications for Treatment of Opioid Dependence. J. Subst. Abuse Treat., 32(2), pp. 207-215, 2007.

Modified Therapeutic Community for Co-occurring Disorders: A Summary of Four Studies

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). The study populations included homeless individuals in New York City; offenders in Pueblo, CO; outpatients in Philadelphia, and HIV+ individuals in Philadelphia, respectively. Across four experimental versus control comparisons, significantly better outcomes for MTC were found on 12 of 52 primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders. Sacks, S., Banks, S., McKendrick, K., and Sacks, J. Modified Therapeutic Community for Co-occurring Disorders: a Summary of Four Studies. J. Subst. Abuse Treat., 34(1), pp. 112-122, 2008.

Data from a survey of 116 outpatient non-methadone treatment programs in four regions of the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) were used to estimate statistical associations between three measures of client contact and various program-level characteristics. Separate multivariate regression analysis was used to examine the effect of internal and environmental characteristics on program level summary measures of the average number of hours a typical client spends in individual or group counseling, the average number of hours a typical client spends in case management, and the average counselor caseload. Results reveal that the average client in public programs received 4.64 more hours of counseling compared with private non-profit programs (p<0.01), and those in nationally accredited programs received 2.14 more hours than in programs without such accreditation (p<0.05), holding other factors constant. The average client in a Southeast program received 4 hours fewer (p <0.01) and Great Lakes almost 3 hours fewer (p<0.05) of counseling than those in Gulf Coast State programs. The average client in programs with a higher proportion of recently hired counselors likewise received fewer counseling hours (each 10% increase was associated with a decrease of 20 minutes, p <0.01). Not surprising programs offering intensive outpatient treatment provided more counseling hours to the average patient. Both public and private for-profit programs reported providing more case management time to the average client than did private non-profit programs (0.86, hours p <0.05; 0.61 hours p< 0.05) but fewer minutes about were provided in programs with a higher proportion of dually-diagnosed (DD) clients (-4.5 minutes for each 10% increase in the proportion DD). Higher caseloads were associated with location in the Southeast, Great Lakes, and Northwest regions (compared with the Gulf Cost region) and having a higher proportion of criminal justice clients. Lower average caseloads were associated with having received national accreditation, while higher caseloads were associated with having a higher monthly client census, a high proportion of CJ clients, and location outside of the Gulf Cost region. Knight, D., Broome, K., Simpson, D., and Flynn, P. Program Structure and Counselor-Client Contact in Outpatient Substance Abuse Treatment. Health Serv. Res., 43(2), pp. 616-634, 2008.

Prescription Drug Diversion and Pain Medication

Prescription drug diversion involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, and can occur along all points in the drug delivery process, from the original manufacturing site to the wholesale distributor, the physician's office, the retail pharmacy, or the patient. However, empirical data on diversion are limited. In an attempt to develop a better understanding of how specific drug-using populations are diverting prescription opioids' and other medications, or obtaining controlled drugs that have already been diverted, qualitative interviews and focus group data were collected on four separate populations of prescription drug abusers in Miami, Florida --club drug users, street-based illicit drug users, methadone maintenance patients, and HIV positive individuals who abuse and/or divert drugs. Sources of abused prescription drugs cited by focus group participants were extremely diverse, including their physicians and pharmacists; parents and relatives; 'doctor shopping'; leftover supplies following an illness or injury; personal visits to Mexico, South America and the Caribbean; prescriptions intended for the treatment of mental illness; direct sales on the street and in nightclubs; pharmacy and hospital theft; through friends or acquaintances; under-the-door apartment flyers advertising telephone numbers to call; and 'stealing from grandma's medicine cabinet'. While doctor shoppers, physicians and the Internet receive much of the attention regarding diversion, the data reported in this paper suggest that there are numerous active street markets involving patients, Medicaid recipients and pharmacies as well. In addition, there are other data which suggest that the contributions of residential burglaries, pharmacy robberies and thefts, and 'sneak thefts' to the diversion problem may be understated. Inciardi, J., Surratt, H., Kurtz, S., and Cicero, T. Mechanisms of Prescription Drug Diversion Among Drug-Involved Club- and Street-Based Populations. Pain Med., 8(2), pp. 171-183, 2007.

Clinicians in adolescent substance abuse treatment programs often recommend attendance at 12-Step meetings; however, there has been no systematic study of their referral practices or possible influence on attendance rates. The authors of this study used quantitative and qualitative data to examine: (a) the self-help referral practices of clinicians employed in adolescent substance abuse treatment programs; and (b) the potential relationship between practices and self-help attendance. Data were analyzed from open-ended interviews with 28 clinicians at eight CSAT-funded SCY sites and from follow-up interviews with over 1,600 adolescents. Results indicated that clinicians referred adolescents almost exclusively to 12-Step groups. Various factors were considered when recommending attendance, including substance use severity and ability to grasp 12-Step concepts. Meeting age composition and availability were common influences when suggesting specific meetings. Clinicians who described their treatment programs as '12-Step based' and actively linked adolescents to groups tended to be employed at sites that had the highest overall rates of self-help attendance. The authors note that if clinicians want to facilitate self-help attendance, providers might assess the 'fit' between individual adolescents and particular meetings. Additionally, programs may want to develop and train staff in standardized referral procedures. Further research is needed to empirically test referral strategies with adolescents. Passetti, L., and Godley, S., Adolescent Substance Abuse Treatment Clinicians Self-Help Meeting Referral Practices and Adolescent Attendance Rates. J. Psychoactive Drugs, 40(1), pp. 29-40, 2008.

A Description of One-Year Treatment Patterns of Adolescents in Addiction Treatment

The American Society on Addiction Medicine's Patient Placement criteria are commonly used in adolescent treatment. However, the use of these criteria and how they affect the course of treatment and interact with adolescent change has not been examined. Twelve-month treatment patterns were examined for 176 adolescents who entered their first ever episode in a treatment system using these criteria. Forty-one percent of the adolescents received additional treatment after their initial outpatient episode with over 30 unique treatment sequences (i.e., various combinations of outpatient, intensive outpatient, and residential treatment). Significant differences in treatment patterns were found between the change trajectory groups. For example, adolescents who participated in only one outpatient treatment episode were more likely to be in the low alcohol and drug use (AOD) group and less likely to have high rates of time in a controlled environment or to report moderate AOD use. Over one-third of the adolescents participated in additional treatment and almost one-quarter of those who only participated in outpatient treatment had problematic use. These findings suggest the need for clinical monitoring protocols that can be used to identify adolescents needing additional treatment or recovery services. Godley, S., Passetti, L., Funk, R., Garner, B., and Godley, M. One-Year Treatment Patterns and Change Trajectories for Adolescents Participating in Outpatient Treatment For the First Time. J. Psychoactive Drugs, 40(1), pp. 17-28, 2008.

Children and Adolescents Treated for General Delinquency Problems and Rated as Having Sexual Behavior Problems Respond Well to Intensive, Caregiver-Focused Treatment

The authors of this study compare children and adolescents treated for general delinquency problems and rated by caregivers as having sexual behavior problems (SBP; N = 696) with youth from the same sample with no sexual behavior problems (NSBP; N = 1,185). Treatment outcome through 12-months post-treatment and criminal offending through an average 48-month post-treatment were compared for both groups. The authors hypothesized that both groups would improve over time; however, the SBP group would evidence greater psychopathology at follow-up, and these hypotheses were supported. It was further hypothesized that youth with SBP would not differ from youth with NSBP in rates of future sexual or nonsexual offenses. These hypotheses were also supported. SBP group membership was not a significant predictive factor in analyses modeling future offending (any) or future person offenses. Few youth in either group had sexual offenses. These results demonstrate that though youth with SBP apparently represent a substantial minority of delinquent youth referred for treatment, these youths appear to respond well to intensive, caregiver-focused treatment and are no more likely to commit future sexual offenses than delinquent youth without SBP when effectively treated. Letourneau, E., Chapman, J., and Schoenwald, S. Treatment Outcome and Criminal Offending by Youth with Sexual Behavior Problems. Child Maltreat., 13(2), pp. 133-144, 2008.

Concensus Among Patients About the Value of Abstinence Leads to Better Treatment Outcomes

Secondary analysis of data from a 'Beliefs about Abstinence Scale', used in the Drug Abuse Treatment Outcomes Study (DATOS), was conducted for 76 programs, including outpatient methadone treatment, outpatient drug-free, short-term inpatient, and long-term residential programs. Findings show that higher levels of client consensus after 1 month of treatment were associated with less use of drugs and alcohol at 1-year follow-up, after controlling for the mean of the scale score, gender, and age, client substance use at baseline and treatment modality. The implications of the results for substance abuse treatment are discussed. Melnick, G., Wexler, H., and Cleland, C. Client Consensus on Beliefs about Abstinence: Effects on Substance Abuse Treatment Outcomes. Drug Alcohol Depend., 93(1-2), pp. 30-37, 2008.

There Is a Successful Model To Help Substance Abuse Treatment Clinics Make a Smoke-Free Transition

This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article reviews the six core strategies used to implement the ATTOC intervention, the 12-Stage approach guiding the model, and describes a case study where the intervention was implemented in a clinic setting. Ziedonis, D., Zammarelli, L., Seward, G., Oliver, K., Guydish, J., Hobart, M., and Meltzer, B. Addressing Tobacco Use Through Organizational Change: A Case Study of an Addiction Treatment Organization. J. Psychoactive Drugs, 39(4), pp. 451-459, 2007.